It would be easy to assemble an All-Star staff of pitchers who have excelled after Tommy John surgery, aces such as Adam Wainwright, Francisco Liriano and Stephen Strasburg who returned from elbow reconstruction as good as ever, and earned tens of millions of dollars thanks to their new ulnar collateral ligaments.

Yet the once-revolutionary surgery has become so commonplace - and successful - that finding an answer for a rash in pitchers undergoing the procedure proves elusive.

Pitchers are throwing harder than ever - and on a year-round basis at a younger age - both of which can add stress to a very delicate ligament.

And oddly, the allure of the cure - and some of the myths it has engendered – may be partly to blame for the spike in the surgery's incidence.

"It seems like every year I'm doing more and more, so from my standpoint it's an epidemic,'' said James Andrews, the noted orthopedic surgeon who has become the go-to doctor for major leaguers with elbow problems.

If Tampa Bay Rays left-hander Matt Moore opts for Tommy John elbow surgery as expected, he will be the 13th major league pitcher to have the ligament-replacement operation since spring training. That's only six fewer than all of last season, and three under the annual average from 2000-2011, according to an industry-commissioned study.

The Atlanta Braves were hit twice last month when they lost Kris Medlen and Brandon Beachy to torn elbow ligaments, wiping out two-fifths of their rotation. This week, Braves reliever Cory Gearrin confirmed he will need the operation as well.

"There's so much information about how good the procedure is that players don't want to wait,'' Andrews said. "They want it done. So it's a struggle. There's always room for conservative treatment.''

There's strong evidence in favor of surgery, though.

Surgery not foolproof

A study published in December in The American Journal of Sports Medicine showed an 83% rate of return to the majors among 179 pitchers who had the operation, and a 97.2% rate of return to pitching in the pros. Only five pitchers in the sample failed to make it back.

And while the typical return from Tommy John surgery takes a year, an unsuccessful rehab may wind up costing a pitcher nearly two seasons, depending on its length and when the injury occurs..

Moore spent more than a month on the disabled list with elbow soreness late last season, then had to leave Monday's game in the fifth inning when pain flared up again. Moore was examined by Andrews on Wednesday, and he and the Rays are weighing which course of action to take regarding his torn ulnar collateral ligament.

"It needs to be looked at a little bit more deeply because it's not a slam dunk surgery right now,'' Rays manager Joe Maddon told reporters Wednesday.

Like this topic? You may also like these photo galleries:

Speaking of players who have faced Tommy John surgery in general, not Moore specifically, Andrews said elements such as the significance and location of the tear, the player's attitude, contract status and the time of the season when they get hurt usually factor into the decision of how to address the injury.

Andrews and Stan Conte, vice president of medical services for the Los Angeles Dodgers, agree some misconceptions about the procedure might be contributing to its increase.

For one, it's not fool-proof.

"General managers, coaches, agents, even players think it's an automatic to get well if you just go ahead and fix it,'' Andrews said. "They don't realize the complications associated with the surgery. There's no injury that can't be made worse with surgery.''

There is also the notion that pitchers throw harder after having the operation – Andrews has had parents bring in healthy teenagers hoping the surgery will add velocity to their fastballs – when in reality it is the strength gained through rehab that may contribute to any uptick in mph.

"There are some myths about Tommy John surgery that (may prompt) people to get the surgery,'' Conte said. "Have you ever seen a pitcher who is not proud of his Tommy John surgery scar?''

Conte is the lead investigator in a study that began in 2012 and surveyed all the major and minor-leaguers to examine their history of injuries and the prevalence of players – mostly pitchers – who had undergone the Tommy John procedure.

Conte said from 2000-11 the average number of these surgeries among major leaguers fell just short of 16, then the figure skyrocketed to a record 36 in 2012 before dropping to 19 in 2013.

"Of course, this year we're definitely ahead of schedule,'' Conte said. "When you look at Tommy Johns from 2003-2013, most of them occurred in June, not in April and May. This has definitely been one of the strongest starts, for whatever reason.''

Figuring out why elbows blow out - this year, perhaps, more than ever - is a question that has vexed an industry in which pitchers are as much assets as they are athletes.

A different species

Glenn Fleisig, research director for the American Sports Medicine Institute in Birmingham, Ala., is working with Conte on the study and is an expert on the biomechanics of pitching.

Fleisig has examined UCL injuries for more than a decade and, like his collaborators, expected their numbers to decrease with better knowledge of their causes and of proper mechanics. That hasn't been the case.

Sports medicine, Fleisig noted, aims to help athletes perform at their best while also avoiding injuries. Sometimes those goals work in unison; in the past decade, they can conflict.

"Through science and medicine (plus training and nutrition), we've enabled more pitchers to maximize their potential,'' Fleisig said. "If you look at any team's major and minor league rosters, they have more guys bringing it at 95 mph than 10 years ago or 20 years ago. But that has come at the cost of the ligaments and tendons.

"As we've optimized your ability to have strong muscles and the ability to use the muscles at the right time with proper mechanics, the ligaments and tendons have not been improved as much as the muscles.''

That's because ligaments and tendons don't get as healthy a supply of blood as the muscles, a physiological fact no amount of training or tender care will alter.

And those on the field confirm that the modern pitcher - while enjoying an era of dominance after years of hitting theatrics - is an entirely different species.

"Velocities are way up," says Boston Red Sox catcher A.J. Pierzynski, a 17-year veteran. "More guys are throwing cutters, more guys throwing sliders. Something has to give. Unfortunately, it seems like the elbow, which sucks."

'More not always better'

Pierzynski also cites another trend that has alarmed those who work in sports medicine. Kids, he says, "are kind of born and bred to be pitchers from 5 years old, 6 years old, and throw so much. It stinks."

Indeed, the proliferation of travel ball - starting several years before the 12-year-olds we see on a national stage at the Little League World Series - makes baseball a year-round proposition at an early age. While pitch counts and innings limits create short-term safeguards against overuse, years of specialization take their toll.

"We mathematically, statistically, scientifically have proven that the kids who play baseball year-round are three times more likely to end up on a surgery table by their 20th birthday that those who don't," says Fleisig, citing a 10-year study targeting teenagers who pitch more than 100 innings in a calendar year.

"We live in a day of specialization where kids love one sport and their parents love supporting them, and there are baseball centers and traveling teams, so instead of playing various sports and having periods of activity and inactivity, kids are having this unnatural cycle of playing baseball all the time, and that statistically seriously increases their chances of getting hurt. More is not always better.''

Andrews says the "real problem" begins in younger age groups, whe npitchers suffer minor injuries "playing year-round baseball, playing in two leagues at the same time, overthrowing, watching the radar gun, trying to increase their velocity beyond the development of that ligament.''

This year's crop of big league victims definitely skews young. Six of the 13 - if Moore is included - are 25 are younger, and Parker, 25, has undergone his second surgery.

That reality has led some clubs to stockpile arms as the best safeguard against the likelihood some pitchers will break down.

The Washington Nationals, for example, had such a surplus of starting candidates during spring training, they could afford to let go of veteran Chris Young – picked up by the Seattle Mariners – and move Ross Detwiler to the bullpen.

Then again, three members of the Washington rotation – Stephen Strasburg, Jordan Zimmermann and Taylor Jordan – have had Tommy John surgery.

"The fact of the matter is, this is an unnatural act every time they throw the baseball, so you worry about it. Everybody worries about it,'' manager Matt Williams said. "They go out there and compete on a regular basis, throw that ball 100 times in a game. There's wear and tear.''

And little guarantee the ulnar collateral ligament holds up.

I don't know if there's really a scientific reason," says Shawn Kelley, currently the Yankees closer and a two-time Tommy John survivor, "other than guys are getting bigger and stronger and throwing harder than they ever did.